Provider Demographics
NPI:1548580541
Name:WILSON, STACY-ANN NICOLE (RT)
Entity Type:Individual
Prefix:
First Name:STACY-ANN
Middle Name:NICOLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:796 NANNYBERRY LN
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-9039
Mailing Address - Country:US
Mailing Address - Phone:252-413-9604
Mailing Address - Fax:704-469-6100
Practice Address - Street 1:796 NANNYBERRY LN
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-9039
Practice Address - Country:US
Practice Address - Phone:252-413-9604
Practice Address - Fax:704-469-6100
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-02
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA-5962227800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified